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" APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 r- P O BOX 2009, STOCKTON, CA 95201 77 IIT EXPIRES 1 YEAR-FROM DATE ISSUED / A f (Complete a Triplicate I Application is hereby made to San Joaq in o t-f r a pe o conetru t and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Cqunty; Pu�]ic Health Services r �� .v A ob Address City acerb/ Lot Size/Acreage s _ r Owner's Name Address �/� jj Phone'2 7 33-L3 IJV D�cJlb, j �S g Contrattor �1, 71 -Address ! 4F License Pho>� 7-�/Z_ TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service well ❑ _ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _lL+ SEWER LINES DISPOSAL FLV_A6 �PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati Dia. of Well Casing .� Domestic/Private Gravel Pack ❑ Tracy Type of Casing S -- _ Specifications i'1 Public CI other 1-1 Delta Depth of Grout Seal _~ evc7 Type of Grout�e/fttL y i Irrigation Z30— Approx. Depth I I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump, H.P. ___ �. State Work Done Well Destruction ❑ 'Well DiameterSealing Material & Depth ! Depth. ; Filler Material & Depth n TYPE OF SEPTIC WORK:,NEW INSTALLATION I I REPAIR/ADDITION I # DESTRUCTION i I (No septic system permitf'dd if public sewer is . ' available within 200 feet.1 Installation will serve: Resicl enc �� Commercial_ Other Number of living units-: - Numberof.bedrooms _r„„ i Character of soil to a depth f"3_feet: f•i X. i Water cable depth SEPTIC TANK ❑ T�e/Mfg4 Capacity + No. Compartments �. PKG. TREATMENT PLT. ❑ C t b f } r tt Method of Disposal ' Distance to nearest: Well Foundation I Property Line LEACHING LINE D No. & Length of lines Total length/size -4 4 FILTER BED Cf bistance to nearest: Well -Foundation Property Line SEEPAGE PITS 11 Depth Size !Number I ' SUMPS CI Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work will be done in-accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin county _ d>. _ . Home-owner or licensed agent's signature-certifies the following: 'I certify that`in the pertormance of the work for which this permit is issued, t shall not employ any person in such manner as-to becom use use blect to woikfnan's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the'work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." v The applicant must all f r all r uirad inspections. Complete drawing on reverse side. r I . Signed X `Title: Date: 1 , `FOA DEPARTMENT USE:ONLY t Application Accepted by '� `� (� Date_ Area p r. r Pit ti Gro t Inspection by Date ��fFinal Inspection by ata d Additional Comments: Applicant—Return._all-copses,toSan Joaquin-Countk_Kblic Health 1 Services, Environmental Health Permit/Services ' 1601 E. Hazelton Ave..;. P 0 Box 2009;- CK 009;Stockton, CA 95201 ' l -1 INFO AMOUNT DUE AMOUNT REMITTED ` CK CASH i RECEIVED BY DATE.,, PERMIT'NO. + EH 13-21(REV.I)n si 1.3C?// d b — S EH .4-2e t 9 Ra --z S36